FOR PEOPLE AND FAMILIES · BEFORE CARE

Know the cost before the care.

The estimate request uninsured and self-pay patients are entitled to, the comparison that tells you whether a bill can be disputed, and the questions that get a price in writing.

Ask for the estimate in writing

Your nameProvider or facilityServiceExpected date

November 2, 2026

[Provider or facility]

Re: Request for a Good Faith Estimate
Patient: [your name]
Service: [service]
Expected date: [date]

To whom it may concern,

I am uninsured, or I will be paying for this care myself rather than using a health plan. Under the No Surprises Act (45 CFR 149.610), please provide a written Good Faith Estimate of the expected charges for the service above, including the codes, the expected charge for each item, and the charges of any other providers or facilities you expect to be involved. Please send it within the time the rule allows: one business day if the service is scheduled three or more business days out, or three business days if it is scheduled ten or more days out.

I understand the estimate is not a contract and that the final bill may differ, and that if the bill is $400 or more above the estimate I may dispute it.

Thank you,

[your name]
[phone and email]

Compare the bill to the estimate

$400 rule

Estimate totalAmount billedDate on the bill

To start a dispute: www.cms.gov/nosurprises or 1-800-985-3059. Keep the estimate, the bill and your request letter together.

Six questions to ask before care

Are you, the facility, and everyone who will treat me (anesthesia, radiology, pathology, labs) in my plan's network?
What codes will be billed, and what is the cash price and my expected share for each?
Does my plan require prior authorization for this, and has it been obtained? Please give me the authorization number.
Is there a lower-cost setting for the same service, such as an office or an imaging center instead of the hospital?
If I cannot pay, what financial assistance or payment plan do you offer, and where is the policy?
Can I have all of this in writing, by email or through the portal, before the appointment?

Most people say their doctor rarely or never discusses cost. Asking in writing creates a record you can hold the provider to.

RVU-based Medicare benchmark, before payer adjustments, OPPS caps, sequestration, and patient cost sharing. An estimate, not a payment guarantee.